Page 13 - SBCEO Benefit Guide 19-20_FINAL

Dental Benefits 13

Dental Plan Options

Delta Dental PPO Incentive Premier Plan
With this plan, coverage begins at 70% and coverage levels increase by 10% each year you are enrolled in the plan (provided
you have two dentist visits per plan year) until coverage at 100%. When you receive services from In-Network dentists, your
out-of-pocket costs are lower. In-Network dentists agree to discount their charges while Out-of-Network dentists do not.
Out-of-Network benefits are based on a program allowance determined by Delta Dental.

Delta Dental PPO Plan
When you receive services from In-Network dentists, your out-of-pocket costs are lower. In-Network dentists agree to
discount their charges while Out-of-Network dentists do not. Out-of-Network benefits are based on a program allowance
determined by Delta Dental.

Anthem Essential Choice Plan
With the Anthem Essential Choice dental plan, you may visit a SISC Dental Health Network dentist and benefit from the
negotiated rate. When you utilize a SISC Dental Health Network dentist, your out-of-pocket expenses will be less. If you
obtain services using a non-network dentist, you will be responsible for the full amount charged by the provider.

Delta Dental PPO Incentive Delta Dental PPO Plan Anthem Essential Choice
Premier Plan #7075 4061 #7075 4261 Plan #4D005A 10421BA
Dental In-Network Premier or In-Network Out-of-Network SISC Dental Health Net-
Benefits Out-of-Network work
Calendar Year Maximum Unlimited Unlimited $1,000 $4,000
Benefit

Calendar Year Deductible None None None Individual: $25 None
Family: $75
Diagnostic & Preventive 70% – 100% 70% – 100% 100% 50% 100%
Services
Basic Services 70% – 100% 70% – 100% 100% 50% 100%

Major Services 70% – 100% 70% – 100% 100% 50% 100%
2 2
Prosthodontics Services 50% 50% 60% 50% 50%
1 1 2 2
Implants 60% 50% 60% 50% Up to $2,000
Orthodontia (All Ages) Not covered 50% up to $2,000 100% up to $2,000
Lifetime Lifetime
1 Implant are paid at 60% in-network limited to a $2,000 annual maximum, 50% out-of-network to a $2,000 annual maximum.
2 Implant are paid at 60% in-network limited to a $2,000 annual maximum, 50% out-of-network to a $1,000 annual maximum.
3 When using the out‐of‐network provider, you are responsible for all amounts exceeding the fee schedule.

Contact Information

 Delta Dental: Call 866-499-3001, visit deltadentalins.com or download the Delta Dental Mobile app
from The App Store or Goggle Play.
 Anthem: Call 844-729-1565 or visit anthem.com/ca/sisc and refer to SISC Dental Health Network.